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NPI Code Detail

MEDICARE: DR. MATTHEW BOLTON MD

MEDICARE: DR. MATTHEW BOLTON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician21614TN
2208D00000XGeneral Practice PhysicianMD21614TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14129250OTHERTNBCBS

General Provider Information

NPI Number : 1720082548
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MATTHEW BOLTON MD
Provider Business Mailing Address
First Line : 1100 ENGLAND DR
Second Line :
City : COOKEVILLE
State : TN
Zip : 38501-0924
Country : US
Telephone Number : 931-528-7531
Fax Number : 931-520-0413
Provider Business Practice Location Address
First Line : 1503 S MAIN ST
Second Line :
City : CROSSVILLE
State : TN
Zip : 38555-5967
Country : US
Telephone Number : 931-484-6196
Fax Number : 931-456-1047
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2005
Last Update Date : 03/17/2018

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